A list of the most recent deficiencies for The Shepherd's Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
---|---|---|---|---|
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-03-30 | 2022-05-12 | N |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-03-30 | 2022-05-12 | N |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-30 | 2022-05-12 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-30 | 2022-05-12 | N |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-03-30 | 2022-05-12 | N |
Post nurse staffing information every day. | Health | 2022-03-30 | 2022-05-12 | N |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-03-30 | 2022-05-12 | N |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-03-30 | 2022-05-12 | N |
Provide and implement an infection prevention and control program. | Health | 2022-03-30 | 2022-05-12 | N |
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-03-30 | 2022-05-12 | N |
Conduct testing and exercise requirements. | Fire Safety | 2021-01-11 | 2021-02-10 | N |
Provide properly protected cooking facilities. | Fire Safety | 2021-01-11 | 2021-02-10 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-01-11 | 2021-02-10 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-01-11 | 2021-02-10 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-01-11 | 2021-02-10 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-01-11 | 2021-02-10 | N |
Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2021-01-11 | 2021-02-10 | N |
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-01-11 | 2021-02-10 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2021-01-11 | 2021-02-10 | N |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-10-29 | 2020-12-08 | N |
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-06-06 | 2019-07-08 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-06-06 | 2019-07-08 | N |
Assess the resident when there is a significant change in condition | Health | 2019-06-06 | 2019-07-08 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-06 | 2019-07-08 | N |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-06-06 | 2019-07-08 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-06 | 2019-07-08 | N |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-06-06 | 2019-07-08 | N |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-06-06 | 2019-07-08 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-06-06 | 2019-07-08 | N |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-06-06 | 2019-07-08 | N |
Provide and implement an infection prevention and control program. | Health | 2019-06-06 | 2019-07-08 | N |
Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-04-12 | 2019-05-28 | N |
Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-04-12 | 2019-05-28 | N |
Develop a communication plan. | Fire Safety | 2019-04-12 | 2019-05-28 | N |
Establish emergency prep training and testing. | Fire Safety | 2019-04-12 | 2019-05-28 | N |
Use approved construction type or materials. | Fire Safety | 2019-04-12 | 2019-05-28 | N |
Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-04-12 | 2019-05-28 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2019-04-12 | 2019-05-28 | N |
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-04-12 | 2019-05-28 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-04-12 | 2019-05-28 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-12 | 2019-05-28 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-12 | 2019-05-28 | N |